Philadelphia is one of the cities hardest hit by the opioid epidemic. Barely a day goes by without news reports of the opioid crisis. Last year, 1,217 people died of overdoses in Philadelphia, and more than three-fourths involved opioids. Sadly, this is a fraction of the over 49,000 opioid-related deaths in the U.S. estimated for 2017. A growing number of overdose deaths today involve heroin with almost 16,000 estimated in the U.S. in 2017, reflecting a 7.6-fold increase since 2002.
The majority of heroin users report that their opioid misuse started with prescription drugs. The lower price and easy access of heroin compared to the high cost and decreased access to prescription opioids has contributed to increased use. In fact, despite a crackdown in opioid prescribing, the numbers of overdose deaths continue to climb, in part because heroin is frequently laced with fentanyl and other synthetic drugs, increasing its lethality, as well as a scarcity of opioid-dependence treatment centers across the U.S.
As a way to combat the opioid epidemic, the Centers for Disease Control and Prevention (CDC) released a guideline in 2016 aimed at reducing opioid prescribing. Within the CDC Guideline for Prescribing Opioids for Chronic Pain, the CDC noted that opioid prescribing had sharply increased over the previous 10 years, resulting in widespread nonmedical use and addiction. The CDC guideline strongly advises against using opioids first-line and recommends doses less than 90 morphine milligram equivalents (MME) per day.
In response to the release of the CDC Guideline many states and the federal government announced strategies and regulations aimed at lessening opioid prescribing and limiting dispense quantities. By the end of 2017, 24 states had enacted legislation with some type of limit, guidance, or requirement related to opioid prescribing. Examples include 3-4 day quantity dispense limits or doses capped under 90 MME per day. Other strategies adopted by states include mandatory checking of prescription drug monitoring programs (PDMPs) to identify persons who may be at risk for addiction or misuse. Some states require PDMP checks for hospice and palliative care patients too.
The CDC Guideline specifically states that it…”is intended to apply to patients aged ≥18 years with chronic pain outside of palliative and end-of-life care.” Subsequently, most of the new opioid guidelines and regulations exclude the hospice and palliative care population, however some pharmacies and regulatory bodies have placed opioid restrictions across the board, thereby reducing access to those with advanced or terminal illness. This, in combination with rising opiophobia and stigma among prescribers, patients and family caregivers, presents challenges to pain and symptom management at the end of life.
Ensuring Safe Prescribing in Hospice During the Opioid Epidemic
Hospice organizations increasingly recognize that a multimodality approach to pain management is needed and are putting opioid stewardship practices in place to ensure safe prescribing, storage, administration and disposal. Examples of best practices for safe prescribing include conducting an opioid risk assessment and identifying who will control medication administration in high-risk households. Some hospices use standard agreements that state clear boundaries of use, disposal and consequences for misuse or diversion – often referring to these agreements as “safety agreements” and using them as a communication and education tools for patients and caregivers.
Hospices are limiting the supply of controlled substances in homes where diversion is suspected or when necessary, and may admit patients to a controlled environment. Hospices can further reduce waste in the home by limiting “as needed” dispenses to anticipated need only and opioids should not be reordered unless necessary, after current supply is assessed. Some states allow hospice nurses to take responsibility for appropriate disposal of unused medications and federal legislation allowing this has strong bipartisan support and is expected to pass soon.
The problem of abuse and addiction to opioids has emerged as a major issue, leading to new Opioid Prescribing Guidelines from the CDC and actions by industry and legislators that affect prescribing. Despite exceptions for hospice and palliative patients, the combination of these new laws and publicity about the dangers of opioids is making it harder to prescribe opioids, access opioids, and convince patients that they are safe to use.
Together, Relias and Enclara Pharmacia provide hospice organizations with the tools to provide comprehensive and compassion care.